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2008
CFMA Insurance Application
Due March 29, 2008
Applications after that date must add $25
Market
name ________________________________________________________________________
Market physical set up location ________________________________________________________
( list address and city)
Actual 2007 gross income of your market organization from fees and other sales:
$____________
Even if you are a “nonprofit”, you must list any money you collected
for fees, etc.
This does not include the sales by your sellers, only income of the market “organization”
itself.
Subtract sales taxes you collect from sellers and pass on to a city, if any.
New markets should estimate fees and other income you expect this season.
List name of any “additional insured” to be included on your proof
of insurance certificate and fill out a Certificate
Request Form for each additional insured (new requirement this
year).
Please check your lease carefully for the exact wording your landlord requests.
If an additional insured requires that an original certificate be sent to them,
please indicate this on the form.
Changes after the first certificate is issued are subject to a $25 extra fee.
If you do not know this info yet, please note below and then notify CFMA as
soon as you do know.
No certificate will be issued until you supply all necessary information.
Please list only landlords or market site property owners or property managers.
Each market is allowed up to two additional insureds, any more
may be subject to a $100 fee.
Your farmers’ market “company”, plus any owners, and market employees
are covered by the policy and will not be added as additional insureds.
Additional Insured(s):
_________________________________________________________________________
_________________________________________________________________________
____
Don’t issue my certificate yet. I will let you know when I get the names
finalized.
It
can take seven to ten working days to get a certificate issued, so please plan
ahead.
Enclose the 2008 premium contribution of $350 per market site, payable to CFMA.
Mail to: CFMA, c/o Sally Haines P.O. Box 4354 Boulder, CO 80306
Name
of person supplying above data
Name ________________________________________ Your title______________________________
(please print name)
By signing here, I acknowledge I have read the 2008 CFMA Insurance Information Sheet document, and the 2008 CFMA Safety Guidelines document, and that the above information is correct at the time of submission.
(signature required) __________________________________________
This information will be handled confidentially for insurance purposes only, and may be audited by the insurance company.